Deisley, Edward NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section r Burial - Transit Permit
Name First Middle Last Sex
Edward Joseph Deisley Female _
Date of Death Age If Veteran of U.S. Armed Forces,
7/10/2018 73 War or Dates Y
1 . Place of Death Hospital, Institution or .` a'
Z City, Town or Village Queensbury Street Address 24 Jerome Ave
QManner of Death I - Natural Cause I 'Accident I l Homicide n Suicide n Undetermined n Pending
W Circumstances Investigation
• W Medical Certifier Name Title
C Dr Gara,MD
Address
Fort Edward,NY
Deat ific Filed District Number aster Number
Cit Town or Vi age C c—1 �
❑Burial Date Cemetery or Crematory
July 13, 2018 Pine View Crematorium
❑Entombment Address
®Cremation _ 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
rA
o Date Point of
a. Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
CC
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 7111 I IS Place of Disposition M....- rMYo s
(address)
Lll
N
o (section) ri
number) (grave number)
pName of Sexton or Person in Charge of Premises ..710L, S 'v`ii,
W
(plea print)
Signature d Title (ir}ii(L
(over)
DOH-1555(02/2004)